Cardioversion

Debbie Sevant BHF Arrhythmia Nurse Specialist Essex Cardiothoracic Centre

Cardioversion
• Safe and effective treatment to restore the heart to a normal rhythm • Common treatment for Atrial Fibrillation • Other rhythms may be cardioverted • Treatment protocols vary

Case Study
• A 45 year old lady with a history of diabetes presented to her GP with shortness of breath and fatigue. • Examination revealed an irregular pulse. • ECG revealed Fast Atrial Fibrillation, heart rate 140 bpm.

Why do I need Cardioversion ?
• • • • • Normal Conduction AF - chaotic electrical activity Causes fibrillation of atria of the heart Loss of atrial kick / contraction Can cause Symptoms & Complications

Symptoms
• • • • • • • • Asymptomatic Mild to severe GP, clinic, urgent treatment SOB Fatigue Dizziness Syncope Chest pain

Complications of AF
• Risk of blood clots • 5 fold increased risk of stroke • Aspirin Warfarin

• Risk stratification CHAD, NICE

Initial Treatment of AF
• Control Heart Rate < 80bpm at rest
– Beta Blockers – Calcium Antagonists – Digoxin – Emergency - Cardioversion

Initial Treatment of AF

• Reduce risk of Blood Clots
– Aspirin – Warfarin

Who is suitable for Cardioversion?

• • • • •

Heart Rate Control
Patients over 65 Patients with coronary heart disease


• •

Cardioversion
Presenting for the first time with lone AF Younger patients Patients with Symptoms Patients with AF secondary to another cause eg. Thyroid abnormality, post surgery

Patients unsuitable for cardioversion • Patients who can’t take antiarrhythmic drugs No Symptoms •

History of Cardioversion
• 1775 Abildgaard
showed that hens could be made lifeless with electrical impulses and he could restore a pulse with electrical shocks across the chest.

First Cardioversion
• 1947 Claude Beck
pioneering cardiovascular surgeon in Cleveland, successfully defibrillates a human heart during cardiac surgery. The patient was a 14 year old boy His prototype defibrillator followed experiments on defibrillation in animals performed by Carl J. Wiggers,

Chemical Cardioversion
• Cardioversion can be “chemical” or “electrical” • Chemicals alter the heart’s electrical properties to suppress the abnormal heart rhythms and restore a normal rhythm • In- Patient • Out-Patient • Common – Amiodarone, Sotalol, Flecainide

Direct Current Cardioversion
• Electrical cardioversion - a synchronized electrical current (shock) is delivered through the chest wall to the heart through special electrodes or paddles that are applied to the skin of the chest and back • Interrupt the abnormal electrical circuit(s) in the heart and to restore a normal heart beat

Procedure
• • • • • • • Hospital Setting Day case Nurse, Anaesthetist, ODA, “Cardiologist” Warfarin levels prevent stroke TOE GA or Sedation Fast 6 hours Take all medication that day except diabetic

Paddle Position

Result

• Synchronised • Amount of Joules • Success 99.4% locally – biphasic technology

Recovery
• • • • • • • • Minor skin burn – common Arrhythmia - bradycardia Clot Event 1 in 100 Anaesthetic Effect Do NOT drive 24 hours No important decisions 24 hours Accompanied home Pacemaker Check

How effective is it ?
• 50% recurrence within a year • Increased risk of recurrence with repeat procedures • Follow Up – Often none – NICE : 1 month & 6 months – RAAF Experience – Consider Ablation

Case Study
• A 45 year old lady with a history of diabetes presented to her GP with shortness of breath and fatigue. • Examination revealed an irregular pulse. • ECG revealed Fast Atrial Fibrillation, heart rate 140 bpm. • Atenolol 25mg od was commenced to reduce her heart rate.

Case Study
• A referral was made to the local Rapid Access AF Clinic and Warfarin was commenced • The Patient was seen in the Rapid Access AF Clinic 2 weeks after referral • Echocardiogram at that clinic showed a normal heart • Admission for DC Cardioversion was arranged once INR was within range • Referral to Treatment 12 weeks

Case Study
• This lady successfully cardioverted to normal rhythm with one 200 joule shock • She was seen 3 months after DC cardioversion in the AF follow up clinic • ECG showed normal rhythm and warfarin was stopped